HEARTBEAT Maurice NeliganPrimum non nocereFirst do no harm has been a guiding principle of medical management since pre-Hippocratic days. Few doctors get up in the morning and say "I'm going to harm somebody today." Yet it happens and will continue to happen as long as mankind is divided into the two categories of doctor and patient.
I have had recent conversations with two patients with widely different conditions, attending two different consultants for their treatment. In both instances, the clinicians had not alone discussed in detail, the diagnosis, prognosis and treatment of their conditions, but had provided a written synopsis of same.
In other words, the doctor was trying to obtain "informed consent" for the proposed course of treatment. What baffled both patients - intelligent and successful in their own fields - was that despite what appeared to me to be lucid explanations of the problems, it was almost incomprehensible to them.
As an intern, getting consent forms signed was part of daily life and by and large the patients accepted the proposed treatment in trust and with good faith.
What has changed of course over the years is the increasingly oppressive climate of litigation. Who can I sue if things go wrong? It must be somebody's fault. They never told me this could happen. Accordingly, now the doctor must explain the nature and extent of proposed treatments and their likely outcomes. He is supposed to list any complications that may arise up to and including death. He is supposed to inform patients of alternative treatments and their purported efficacy. In the US, this must include the likely costs involved.
All of this ignores one basic problem - the patient, in the absence of a medical degree, does not have the knowledge to engage meaningfully with the doctor. Many doctors entrusting themselves to their specialist brethren do not understand the intricacies and problems known to the specialist. But they do have the knowledge and sense to trust.
So how far is the profession to go in establishing informed consent? One little example: the California supreme court on the risks of having blood drawn listed haematoma, dermatitis, cellulitis, abscess, osteomyelitis, septicaemia, endocarditis, thrombophlebitis, pulmonary embolism and death. It stressed that the list was by no means complete. Another publication listing complications of back surgery listed 146 complications with the same caveat as before. So how far do we go?
Does the doctor list every known complication of the procedure or just those more likely to occur? If, by listing every known hazard, he scares the patient so completely that the treatment is declined, he may be deemed negligent for so doing. If he omits complications and sequelae which might seem obvious, he can also be deemed negligent.
If the doctor makes a judgment call that the patient is incapable of grasping the intricacies of what is proposed, he becomes totally politically incorrect, and indeed elitist and arrogant. However, I have said this before and I will say it again, the interaction of the doctor with patient is not simply "primum inter pares", it should be knowledge and compassion on the one hand and trust on the other.
There is no clear exposition of this problem in law and no universally accepted code of best practice. A formula such as "all risks were discussed, all questions answered, informed consent given" should be unfailingly entered in the patient notes. It may provide at least some protection when the "wherefore you did mangle my client" letter arrives. The inevitable consequence of all of this is more defensive medicine and less productivity. If there is more law, there is less medicine. It is little wonder that St Luke is our patron saint.
"Woe unto you lawyers! For you have taken away the day of knowledge." (Luke ch.11 v.52)
Maurice Neligan is a cardiac surgeon.